198 previously untreated consecutive patients with chronic HCV were included.
All patients had serological, virological, and histological evidence of
chronic HCV. Patients with any other confounding chronic liver disease
were excluded. Demographic and laboratory data were collected for each
patient at the time of liver biopsy. Data of liver biopsy including degree
of activity, stage of fibrosis and degree of steatosis were also collected.
Patients with normal ALT were identified and follow up data for ALT were
collected to identify those with persistently normal values.

Normal ALT at the time of first evaluation was found in 25 out of 198
patients (12.7%). There was no significant difference between patients
with normal ALT and patients with high ALT regarding gender, age at infection
time, duration of infection and route of acquisition. Patients with normal
ALT had lower AST level (P = 0.0005), lower serum bilirubin (P = 0.01),
lower serum iron (P = 0.003) and lower body mass index (P = 0.03). Severe
hepatic fibrosis (stage III, and IV) was found in 52/173 (30%) patients
with high ALT compared to 6/25 (24%) patients with normal ALT (P = 0.5).
Hepatic inflammatory activity was substantially less in patients with
normal ALT compared to those with high ALT (P = 0.03). Follow up data
for 18 normal ALT patients showed that only 7 (39%) had persistently normal
ALT values. Results did not change when comparing those with persistently
normal ALT to patients with high ALT.

In summary:

A single normal ALT value at the time of first evaluation is relatively
common in chronic HCV patients.

Most patients with a normal ALT value at the time of first evaluation
did not have a persistently normal ALT.

Patients with normal ALT (single time or persistently) tended to have
lower body mass index and hepatic inflammatory activity but were not less
likely to have severe hepatic fibrosis.

A normal ALT in chronic HCV patients should not preclude liver biopsy
examination or therapy.